Choice, Liberty, and the Texas Filibuster

Has anyone noticed a "national conversation" about abortion?

Long ago I lost count of the number of things about which it has been said we should have a national conversation.  Budgets and fiscal restraint.  Universal health care coverage, whether we should have it, how to pay for it, whether that will lead to "socialized medicine," and whether socialized medicine (like England's National Health Service) would be good or bad for the United States.  Energy policy, and all of its accompanying issues, especially energy independence, renewable resources, and climate change.

I like the idea of a national conversation.  I think of a conversation as two or more people settling into comfortable chairs to have an exchange of ideas about a topic of some importance or significance.  The purpose is to give everyone some insight into the subject, including how others think.  Ideally, if it's a national conversation about something of national importance, it should enable the development of consensus.  That isn't always possible, but it's worth a try.

We don't seem to do this very well.  The art of conversation requires active listening and a mind that is willing to entertain others' ideas and be open to the possibility that divergent viewpoints are meritorious.  Our "national conversations," however, tend to be more like single-minded monologues.  You express your views, while I am focused on what I'm going to say when you're finished.  If I'm listening to you at all, it is only so that when it's my turn to talk, I can make sure I include a pointed refutation of anything you've said.

Is it any wonder that consensus has so persistently and repeatedly eluded us on issue after issue?

This happens because we form opinions quickly and adhere to them tenaciously. Once we've made up our minds, we are very selective about the opinions of others we are willing to hear.  If you are to the left on the political spectrum, you would no more watch the Fox News Channel than go to a Klan meeting.  If you are a political conservative, watching MSNBC is reserved for a day that might otherwise be spent reading Das Kapital, say, the second Thursday of next week.

Climate change?  Evil humans are destroying the earth.  No, idiots believe we are changing the climate, as if we have the power to alter God's plan, when there have been much larger changes in climate than this one over the course of our planet's history.

Health care?  Corporate greed precludes any possibility of rational allocation of resources, steadily widening the gap between rich and poor.  No, socialists want to destroy the world's best health care by turning it over to mindless bureaucrats who will assure that all of us get health care of equal mediocrity.

Fiscal policy?  We are irresponsibly burying our children and grandchildren under mountains of debt.  No, the deficit doesn't matter, and cutting the federal budget by 2% will inflict unimaginable suffering upon orphans, widows, and others unequivocally deserving of our generous help.

Perhaps no issue highlights our inability to engage in civil discourse better than abortion.  Extreme views dominate the debate.  On one side is the position that life begins at conception and abortion is murder.  The opposing view is that personhood begins at birth, and before that the only consideration is a woman's right to control her own body.

When do we hear a national conversation - one that meets my definition - about this issue?  That's right.  Never.  The most recent event to gain national attention in connection with abortion was that exact opposite of a conversation: the one-person filibuster.

To remind those whose memories of high school or college political science have dimmed, when a deliberative body is debating something, there are rules about how long debate can go on.  In some contexts, such as the United States Senate, debate can go on ad infinitum unless there is a successful motion to close debate, called cloture.  In that body, cloture requires 60 votes, rather than the standard 51-vote majority.  So if there is someone who wants to debate something endlessly, and there aren't 60 votes to invoke cloture, whatever it is will never come up for a vote.  Rules vary about whether debate must actually be going on continuously around the clock, and in the US Senate that typically isn't actually necessary to filibuster a bill, preventing it from coming to a vote without a 60-vote "super-majority" to close debate.

The Texas Senate was considering a bill to impose various restrictions on access to abortion.  I will not describe them here, because it is not my intent to focus on the details, but I can assure you that the pro-life folks think they are all eminently reasonable, and the pro-choice camp finds them all quite unacceptable and intended to keep any woman from ever getting a safe, legal abortion: in short, another battle in the Republican Party's "war on women."

Texas State Senator Wendy Davis took to that chamber's floor this week to filibuster the abortion bill.  The idea was that she would speak on the issue without interruption (as required by Senate rules for debate to go on without the matter coming to a vote) until the scheduled end of the session, thereby keeping the Senate from voting on the bill before adjournment was mandated by the clock.

I believe Senator Davis's filibuster was available for watching and listening in various ways, probably including C-SPAN and live Internet streaming.  I must admit I didn't have a chance to watch or listen to any of it.  But I think I can be confident that she did not spend her time examining the arguments for and against each feature of the bill in a carefully balanced way.  That isn't what filibustering politicians do.  A filibuster isn't a national (or state) conversation.

Can we have a national conversation on this issue?  I believe the answer is yes. And I believe the key to doing so is a willingness to accept the notion that this is an ethical dilemma.

About three decades ago I began to develop a keen interest in biomedical ethics. One of the constant features of this realm of thought is the ethical dilemma. Someone is having trouble figuring out the right and wrong in a situation because it isn't obvious.  Arguments can be made on either side that seem to make some sense.  Clearly issues of health, and life and death, fall into the realm of biomedical ethics, and when right and wrong are not straightforward, ethicists will frame a dilemma.  This requires defining, and then comparing, competing interests.

In my view, the competing interests here are clear.  On one hand is a woman's interest in controlling her body and what happens to it.  On the other is the interest of the unborn child in surviving to viability outside the uterus (which usually means birth).

In 1973 the United States Supreme Court espoused the principle that, in general, state abortion laws may not restrict access to abortion before fetal viability but may do so afterward.  (This creates its own difficulties, in that advancements in medical technology can make the age of viability something of a moving target, but that's a big subject all by itself.)  So the Court cast the competing interests in black-and-white terms.  Before viability, a woman's interest in controlling her body is paramount; afterward, the state may consider the interests of the fetus and impose restrictions.  Black-and-white terms.  Suitable for application of law.  Note that the Court is not a group of nine ethicists.

The great difficulty in having a national conversation is that the debate is dominated by those who refuse to accept the notion that there is an ethical dilemma, that there are competing interests to be defined and weighed against each other.  No, there is only one interest, and what that is depends on which side you're on.  Either the only interest is the woman's right to control her body, or the only interest is the baby's right to life.  Anyone on the other side of the debate is either a baby killer or is waging a war on women, condemning them to being maimed or killed through back-alley abortions with wire clothes hangers.  Plain and simple.

But it's not plain and simple, and until we stop pretending it is, the national conversation will never take place, consensus will never emerge, and this issue will continue to be among the most divisive that our society has ever seen.

There is, I believe, no doubt about the path we should follow.  But we will never take the first step along that path until we admit that others' views may have some merit.

  

DOMA and California Proposition #8: Excedrin Headache #2013

Today has yielded what we have come to expect from the month of June: interesting and important rulings in cases brought before the Supreme Court of the United States.

One of the rulings was on the federal Defense of Marriage Act (DOMA), enacted by Congress in 1996 and signed into law by President Bill Clinton.  Section 3 of the Act declared that many aspects of federal law that applied to married couples would apply only to opposite-sex couples.  Same-sex couples who were married in states granting marriage licenses to such couples would not be recognized as married with respect to many provisions of federal law for which marital status is determinative, including taxes and various federal benefits.

An avid student of constitutional law for many years, I was fascinated by this case.  On the surface it seemed pretty simple.  Two couples married in New York, one heterosexual and the other homosexual, would be treated differently under federal law solely because of their sexual orientation.  Surely there must be something wrong with that.  The Fourteenth Amendment to the United States Constitution says that no state shall "deny to any person within its jurisdiction the equal protection of the laws."

There is a judicial principle called the Doctrine of Incorporation that has been used to apply Constitutional protections written in relation to Congress to state governments (notably so for various protections in the Bill of Rights), and in reverse it has been used to apply restrictions on state governments (especially those in the 14th Amendment) to the federal government.  Thus the Equal Protection requirement of the 14th Amendment applies to the federal government, and this section of DOMA violates it.

But then I started reading the Court's opinion and was reminded that among the questions the Court must always consider are whether it has jurisdiction and whether the litigants have standing.  So, to make up an absurd example, if on my commute to work every day I pass a house painted orange with purple polka dots, I may not file suit against the owner and expect the Supreme Court to accept the case.  My opinion that the house is ugly does not give me standing, and the Court does not have jurisdiction, because if the appearance of the house violates anything besides my esthetic sensibilities, it would likely be a city ordinance.

The Court spent several pages on this question, because it was not so obvious. You see, the plaintiff claimed standing because the federal government required the payment of estate taxes by failing to recognize a marriage recognized by the state of New York.  Had the marriage been recognized, the plaintiff would have been exempted as a surviving spouse.  The plaintiff paid the tax, thereby sustaining an "injury," and then asked the IRS to refund the tax because refusal to recognize the marriage was wrong.  Lower courts agreed and ordered the IRS to refund the tax.  The federal government agreed to do so.  The case wound up before the Supreme Court despite the fact that lower courts had ruled in favor of the plaintiff, and the federal government was not arguing that DOMA should be upheld.

So the Supreme Court has issued a ruling in a case in which the litigants before it were in agreement, and it did so by claiming that the case was sufficiently important that it should issue a ruling on the constitutional question even though the matter of damages had already been settled.  As Antonin Scalia explained in his dissent, the rationale used as the basis for so doing is most peculiar, and it raises questions about whether the Court might begin ruling on constitutional issues without having before it a case in which the issues are raised in a concrete circumstance.

This gives me a headache.  Sometimes these questions seem straightforward. Let's say I think the other part of DOMA, which says states don't have to recognize marriage licenses granted to same-sex couples in other states, is wrong.  I cannot challenge that law in the federal courts, because I lack standing. I haven't been harmed by the law.  If I were a member of a same-sex couple who married in Massachusetts and then moved to Alabama, and Alabama's refusal to recognize the marriage caused some tangible harm, I could sue.  But if a federal court ordered Alabama to rectify the harm (without nullifying Alabama's broader statutory refusal to recognize same-sex marriages from elsewhere), and Alabama agreed to comply with the order, I would not have standing to take my case further up in the federal court system.

Lower federal courts often try to resolve cases without ruling on constitutional issues, and cases that appear to involve constitutional issues typically don't reach the Supreme Court unless they get there because the constitutional issue must be addressed to resolve the case.  (Disclaimer: I am not a constitutional lawyer, nor do I play one on TV.  This is just the impression I have formed.)

So, the bottom line is that I think the Court's ruling is correct, and even if Scalia is right that the Court had no business issuing a ruling in this case, it is logical to surmise that another case would have come along eventually in which the Court would have properly issued an opinion.  So why now?  Well, the Court argued that if it waited for another case, many people would have been harmed by DOMA's Section 3 in the meantime.  That seems a sound practical argument. But I can't help thinking, intellectually, that Scalia's argument about ruling on constitutional issues only when requisite conditions have been met is correct. And so I have a headache.

And then the headache got worse when I started pondering the ruling on California's Proposition #8.

The California Supreme Court said the state constitution required, as a matter of equal protection, that the Commonwealth allow same-sex couples to marry.  The people of California (some of them, that is), disagreed and said if the state Supreme Court insisted on interpreting the constitution that way, they would amend the constitution to clarify that "marriage" was for one man and one woman. The referendum to amend the state constitution went on the ballot as Proposition 8 and was approved.  In the meantime, some marriage licenses had been issued to same-sex couples.  Opponents of Proposition 8 filed suit.  The California Supreme Court said the amendment was valid.  All of the legal protections typical of marriage were left in place by Proposition 8, which had no effect on domestic partnerships recognized under state law.  And marriage licenses issued between the original ruling and the passage of Prop 8 were "grandfathered."  The one thing clearly denied same-sex couples, however, was the label "married."  And that was grounds aplenty for them to fight.  Subsequently, federal courts invalidated Prop 8, saying the voters could not, by amending the constitution, take away a right that had previously existed without a compelling reason for doing so.  (Never mind the question of whether that right existed before the California Supreme Court said it did or that that same Court had upheld Prop 8.)

So now the proponents of Prop 8 want to challenge the decision of the lower federal courts.  And the Supreme Court says no.  Why?  They - the proponents of Prop 8 - have not been harmed by its having been struck down, and so they lack standing.  The U.S. Supreme Court thus lets stand the lower federal court rulings, Prop 8 remains invalidated, and California can once again issue marriage licenses to same-sex couples.

In one case, the Supreme Court says litigants who have not been harmed lack standing.  In the other case, the Court says the litigant has standing, and the Court has a basis for issuing an important ruling, even though the claimed harm has been addressed by a lower court ruling.  To add an interesting wrinkle, the IRS had agreed to comply but had never actually given the plaintiff her money back, and the Court said if she had gotten her refund, the answer to the question of standing might have been different.  But instead of just telling the IRS to give her back her money....  Well, you already know the rest of the story.

In both cases there were questions of standing and jurisdiction.  In both cases I am content with the outcome.  But the inconsistency of the reasoning gives me a headache.  Scalia's opinions were the same, saying the Court should not issue a ruling in either case.  The consistency of his argument is compelling.  Oh, and if you've never read any of his opinions, his opinion in the DOMA case is worth the read.  Even though I like the Court's ruling, his dissent is much better written and more logical than the majority opinion, and - frankly - entertaining.  He never disappoints me.

Paula Deen and the "N" Word

I do not watch cooking shows.  Not any more, that is.  I used to watch Julia Childs (The French Chef), but only because my mother did.  The Food Network and my television are strangers.  The ratio of time on ESPN to time on The Food Network at my house approaches infinity, falling short only because I once paused while scrolling to take brief notice: Oh, that's who Paula Deen is.

Now I see she is in the news.  Something about a racial discrimination lawsuit, and the question was posed to her whether she had used the "N" word.  The answer was yes.  The woman is 66 years old and grew up in the American South.  Would anyone believe her if she had said no?

I have always been fascinated by the use of words.  So what about the "N" word? Superficially, its origin is straightforward.  Black.  Same as negro.  Same root as place names Niger and Nigeria.  That reminds me of a Philadelphia city councilman who was introducing dignitaries visiting from Nigeria and referred to them as "our friends from Nigeria," except that he pronounced the first two syllables of that country's name like the racial slur: "nigger-ee-yah," accent on the "ee."  I couldn't believe my ears.

So the "N" word means black.  But it means so much more.  It means, typically, that the user of the word regards black people as different.  It says your people are different from mine, inherently inferior, and deserving of disdain or even hatred.  That is a lot to pack into a single word.

Throughout human history we have identified others as being different from ourselves in various ways, including appearance and belief systems. Having thus characterized them as different, we have used those differences as a pretext for fighting wars against them, taking their land, and raping, brutalizing, killing, or enslaving them. By contrast, the modern era is a period of relative enlightenment, running counter to the patterns of behavior that have marked most of the story of our species.

But the contrast is less marked than we should hope.  I am only a little more than a decade younger than Paula Deen, but I grew up in one of the nation's most segregated cities (Philadelphia), and racism was everywhere.  And it was bidirectional.  I experienced physical and verbal abuse because I was white.  I was ignored and refused service in a diner because I hadn't realized it was in a black neighborhood where I was unwelcome.  And there was plenty of use of the "N" word.

When I was in college there was one summer I worked in a genetics research lab during the day and drove a cab in the evenings.  One evening I was driving down a street in North Philly being stared at by children playing on the sidewalks.  It took a bit of thought to realize their faces bore expressions of wonderment because they had never seen a white person, except on TV.  That is segregation.

We all know the "N" word's meaning varies with the user.  When blacks use it themselves, it can be funny, teasing, playful.  But it can also be scolding.  I know better, as an outsider, than to try to sort out those nuances.  It does, however, trouble me that sometimes it may reflect at least a little bit of self-hatred, a phenomenon all too common among members of minority groups struggling with opposite impulses to assimilate into a culture that often denigrates them while maintaining their distinct identity.

I had a friend in high school, now an attorney, who used a different "N" word.  At the time I had little insight, but now I find it disturbing.  It reflected some of that group self-hatred.  Socioeconomically he was a member of the black middle class, but he lived smack in the middle of the urban ghetto.  And he regarded the black urban underclass as different, in much the same way middle class whites did.  He referred to them with obvious disdain.  His "N" word was "the natives."  In using that word he was labeling them as different, recognizing that their milieu was far removed from white middle class society, which was the stratum of America in which he saw himself belonging.  The choice of word conjured up an image of African tribesmen, scantily clad, such as one might find on the pages of a contemporary issue of National Geographic.

Usually when I write an essay for this blog, I think I have some little topic of interest all figured out - at least to the point of being able to capture the important questions we should be asking about it and trying to answer.  The "N" word is an awfully large subject for a brief essay.  I have been reading Michael Burlingame's superb biography of Lincoln.  It is definitely a "man and his times" sort of opus, and so there is much to learn about 19th-century America within its pages.  The attitudes of white America toward blacks are shocking.  The use of the "N" word is painfully ubiquitous.  Burlingame pummels the reader with it in certain passages, perhaps because he knows the modern reader otherwise just won't "get" the difference between the way whites viewed blacks then and now.

There have been times when I've thought there was an awful lot of fuss being made over the "N" word.  After all, blacks sometimes use it themselves.  And what blacks want to be called has changed from generation to generation.  There was a time when they had no problem with being called "colored."  The organization NAACP captured the legitimacy of that word in its name.  Then they preferred Negro, then black, and now African-American.

But there is no question that the fuss made over the "N" word is very real, and very important.  It bears all of the intense hatred toward others who are different. It is a reflection of the deeply troubled history of relations between the races in a country whose founders were unable to abolish the great evil of African slavery, who instead wrote it into our Constitution.  Jefferson knew it would later ring "like a firebell in the night" and tear the nation apart.  A century and a half ago it did just that.  The process of reconstruction, begun after the Civil War, continues today. And the "N" word gets in the way, every time it is used.  

The Anniversary Phenomenon

Life is full of personal tragedies.  Events that bring great sadness and intense grief are inevitable.  Those who have experienced them often discover the anniversary phenomenon.  When the event was a death, this may occur on the anniversary of the death, or it may be on the person's birthday.

Julia Grace was born on June 5, 1989.  So today she would have been 24 years old.  That is how I have thought about it every year.  She was little past three months of age when she died.  Sudden infant death syndrome (SIDS) is surely one of the most wrenching things that can happen to a family.  Parents blame themselves, or each other.  The sense of loss is overwhelming.

I have never thought of myself as an emotionally open or demonstrative person. Before that day in September, I think I had not cried since I was a small boy.  But Julia's death began a period of many months during which there did not pass a single day on which I did not, at some point, find myself in tears.

Donna, my wife, blamed herself.  I knew that was a normal reaction.  I devoted a lot of time and effort to trying to convince her that it was not her fault.  At the very least, I wanted her to know that I held her blameless.  SIDS has torn apart many married couples.  That would not happen to us.  She sought counseling and found a support group.  It seemed to help.  And she read books.  When Bad Things Happen to Good People, by Rabbi Harold Kushner, was very good.  And When Mourning Comes: A Book of Comfort for the Grieving, by William Silverman and Kenneth Cinnamon, also offered some insight and solace.

I briefly perused the books.  The support group was not for me.  I didn't want to talk about it.  Not about the death, not about my feelings.  I was not shutting out the event or pretending the grief wasn't there.  I just didn't want to talk about it.  I would look inward.  Introspection was my nature.  I would wrestle this demon on my own.  I knew that every time I pinned it, it would get back up.  I also knew that it would eventually realize it could not destroy my inner peace, and it would give up.

I was wrong.  It has never given up.  It comes around every June 5th to remind me how I felt that day when we found Julia Grace in her crib, motionless, not breathing, with a slightly dusky color.  She had not been ill in any way.  She was an extraordinarily pleasant infant.  She was easy to care for, fussed little, cried less.  Other infants, including her older sister Diana, could be fussy and cranky even when they were entirely well.  Diana didn't sleep through the night until I don't know when, but it seems it was long after that should have happened.  And she was a bit colicky.  Not Julia.  She was placid.  When she wasn't happy, she frowned.

Donna and I couldn't help finding this amusing.  It was just part of the whole package.  A very pleasant baby who let us know, on the infrequent occasions when she was out of sorts, with a frown.  No screaming.  No fussing.  Just a frown.

I read a lot about SIDS.  I found a research neonatologist, Robert Guthrie, who could tell me what was known about the syndrome.  There was (and still is) much more unknown than certain.  I invited Dr. Guthrie to the small town where I was practicing emergency medicine at the time to give a lecture on the subject for the hospital's medical staff, most of whom knew as little as I did about it.  They all came, even the ones whose medical specialties would never bring them into contact with SIDS babies or grieving parents.  I thought it was because they were interested.  Only over the subsequent years did I realize they were there to show their sympathy with my sense of loss.

I learned about how people don't know what to say.  I was very fortunate, though, in that I was surrounded by people with enough insight to know it didn't matter what they said.  All they had to do was ask, "How are you doing?"  I would talk if I wanted to, and they would listen, and they knew that was the right thing to do. Mostly I just said the pain was diminishing very gradually, and I was hopeful that eventually life would get back to normal.

Equally fortunate was the absence of people foolish enough to say, "I know how you feel."  Because no one does, unless there is truly a shared experience.  And I guess that's what support groups are for.  But I didn't care about talking to people who really did know how I felt.  I was entirely satisfied just to know that my friends cared about how I felt, even if they couldn't fully understand it.

Always one to try to look on the positive side of things, I must say that was quite a challenge.  I was quite sure there was no positive side, no redeeming virtue to this event in my life that I would have given anything to have been spared.  And then I found myself talking to a mother whose young infant had just died of SIDS. Found at home, EMS summoned, resuscitative efforts unsuccessful, as they almost always are.  And this young woman was beside herself with grief.

I knew how she felt.  What were the odds?  How likely was it that the doctor at the hospital to which her lifeless infant was taken would really know what she was going through?  I knew she wouldn't remember much of what I said to her that day.  So I focused on just two things.  First, I told her mothers blame themselves, and it was important for her to know it hadn't happened because of anything she had done or failed to do.  Second, I said it was important for her to know it hadn't happened because she was being punished for not being a good enough mother or for anything she may have done in her life that she regretted. And I told her if she wanted to talk to someone who could give her medical information about SIDS and also understood what she was going through, she could call me.  Then I called her pediatrician and set in motion the series of events that must follow any sudden, unexpected death.  I hoped the medical examiner would be as caring and respectful as the one who had investigated Julia's death.

Over the years since, this scene has been replayed too many times, although the incidence of SIDS in the United States has declined by about 50% since then. The teaching of parents to put infants to sleep on their backs may be playing a role, although that, too, is incompletely understood.

Shared experience makes the difference between sympathy and empathy.  As I look back over the last 24 years, I still would give anything not to have had the experience that enables me to feel genuine empathy with grieving parents.  But I cannot change that, and so I will make the most of it by using it to help others when I can.

  

Is It My Heart, Doc?

This is an important question.  And I have to try to answer it every day. Sometimes several times a day.  Patients come to the emergency department with pain in the chest, or some other symptoms that make them worried about a heart problem.  Maybe walking up steps and getting winded, with some aching in an arm at the same time.  People worry about their hearts, and for good reason. The body doesn't work very well if the heart doesn't.

The answer can be straightforward.  It may be quite obvious that it's really not a heart attack but indigestion.  Some acid produced by the stomach has escaped upward into the esophagus.  The lining of the esophagus doesn't have the stomach's natural protection against that acid, and inflammation, with a burning pain, ensues.  Reflux esophagitis.  No, it's not your heart.  Pain from a diseased gall bladder can also mimic a heart problem.  And we can often tell the difference fairly easily.  Sometimes pain in the ribcage can be worrisome to the patient yet readily distinguished by the astute clinician.

It would make my job so much easier if the answer were always obvious.  When it really is the heart, it can be quite clear.  Anyone who has been a paramedic, or a nurse or doctor who takes care of emergency patients for years, can often tell when first laying eyes on such a patient.  Uh-oh.  Some heart attack patients just have that look.  And then the story, and the findings on physical examination, and the appearance of the electrocardiogram (ECG) just confirm the initial impression.

Sometimes the story and the examination are not clear-cut, but the test results give us a definite answer.

Yet patients with symptoms suspected of being of cardiac origin are a constant challenge because the initial evaluation in the ED - history, examination, ECG, lab tests - still leaves us uncertain about whether this is really a heart problem.  And the patient will require further evaluation.  Uncertainty is not a good thing when what we're uncertain about could be life-threatening.  People expect - and it seems to me a very reasonable expectation - a high level of diagnostic certainty when there is concern about something that could kill them.

Just what level of certainty should we be going for?  I have written before about the quest for diagnostic certainty, and about how we - and by "we," I mean both doctors and patients - should be asking ourselves whether it makes sense to devote a lot of time, effort, and money to additional testing to raise the level from 93% to 97%.  But remember, if it's 93%, that means being wrong roughly one time out of fourteen.  I'm OK with being wrong one time out of fourteen for some things. For example, if I think you have strep throat and want you to take penicillin, and I think it's unnecessary to waste time and money on a confirmatory test, what happens if I'm wrong?  The penicillin is very unlikely to cause any harm.  Serious reactions are quite rare, and I don't worry much about increasing bacterial resistance to it, because most bacteria are already resistant to it.  The strep that causes throat infections just happens to be an especially dumb bug, so penicillin still works.

But I don't think it's OK to be wrong one time out of fourteen about whether you have something that could cause severe, permanent disability or sudden death. Neither do most of my colleagues or most of my patients.  I guess some people are OK with that level of risk, but then some people jump out of airplanes, too. Yes, I realize that the frequency of the parachutes not opening is far less than one out of fourteen, but when it happens, the results are ... well, you know.

So we tend to be very cautious with ED chest pain patients.  We have all sorts of "tools" at our disposal to try to figure out what's wrong with them, and in particular whether it's a heart problem.  This is an area of intense clinical research: what is the best strategy for assuring that, if we send somebody home from the ED, the likelihood of something bad happening is vanishingly small?  (Or at least down in the 1% range, because no strategy that involves human beings is going to be right 100% of the time.)  We have a standardized name for the "something bad happening," too: MACE, which stands for Major Adverse Cardiovascular Events. Our medical journals have many published papers on strategies for evaluating ED chest pain patients to assure that the likelihood of MACE in the next 30 days (the most commonly used time period) is as low as possible.  Oh, and just in case you are worried about day 31, which I am, the better studies keep track of the patients out to a year.

You probably won't be surprised to learn that most of the patients we worry about turn out not to have heart disease as the cause of their symptoms.  That's what happens when you try to make sure you aren't missing anything.  The more diligently you pursue the goal of catching every potential life-threatening problem (thus avoiding the "false negative" result of your evaluation), the more false positives you are going to get: we were worried about your heart, but all of the tests are normal, so we're now as certain as we can be that it's not your heart. The perfect strategy for evaluating anything would have no false negatives and no false positives.  Unfortunately, that doesn't exist.

You probably also won't be surprised to find out that there is pushback.  All of this evaluation, and especially some of the more sophisticated testing, costs money. If you are a legislator, a regulator, a bean counter, or for any other reason interested in controlling health care expenditures, you are going to take a hard look at a part of the health care system that devotes significant resources to a specific patient population and seems to have a "low yield" relative to dollars spent.  An editorial in the New England Journal of Medicine last year said this:

The underlying assumption ... is that some [more definitive] diagnostic test must be performed before discharging these low-to-intermediate-risk patients from the emergency department.  This assumption is unproven and probably unwarranted.

Now, I'm as much of an enthusiast as anyone I know for the cost-efficient practice of medicine.  And so I'm torn between two impulses here: the first impulse is to agree with an editorialist who clearly shares my bias in favor of a cost-efficient approach.  The second impulse is the one that always seizes me, making me rub my hands with glee, any time I find that one of the world's most prestigious journals has published something stupid.  Remember, I'm a critic. And this statement is most assuredly stupid.

Guess who has the job of "stratifying" risk in this patient population?  Yes, 'tis I, your faithful blogger.  I'm the one who has to separate the high-risk patients from the rest and then decide what to do with the low-risk and the intermediate-risk patients.  And so I read the journals, always looking for the best strategy.  There are certainly some low-risk patients who can go home after a simple, brief, and relatively inexpensive evaluation.  Everyone else needs more.  And it's my responsibility to identify the cut-point.  Sometimes it's not straightforward.  I have a conversation with the patient about my risk analysis.  Some patients are worriers and very nervous even about fairly low-risk situations.  They are afraid to go home from the hospital without a higher level of diagnostic certainty.  And I respect that.  Other patients are skydivers.  They want to stay in the hospital as much as I want to go to ... oh, pick something, because whatever I pick (say, Wagnerian opera), I'll offend somebody who likes it.  "Doc, your best guess is that it's probably not my heart?  That's good enough for me.  I'll call my doctor Monday and then she and I will decide about further testing."

Recently one of the emergency medicine residents (doctors in training) I supervise had a patient with chest pain.  The initial results came back, and we agreed the patient should stay in the hospital overnight for further evaluation.  The resident called the hospitalist - an internal medicine specialist whose practice consists of taking care of hospitalized medical patients - and found that the hospitalist thought the patient should be discharged.  But he came to the ED, saw the patient, and arranged for him to stay the night and have further testing.  He gave the EM resident a copy of a paper published in a major journal on this very subject, to support his opinion.

Last week we had Journal Club, that monthly gathering at which we discuss important papers from medical journals that might have implications for the practice of our specialty.  This particular resident and I quickly agreed that we should include this paper.  By now you can tell that, after my first quick read, I was rubbing my hands with glee.  It was the worst paper I'd ever read on the subject.

Let me reiterate: I am an enthusiastic proponent of the cost-efficient practice of medicine.  The percentage of our Gross Domestic Product that we spend on health care is now in the high teens.  At the beginning of my career it was in the low teens.  The upward slope cannot go on indefinitely.  We have to find ways of getting better health outcomes for less money.  And I believe we can do that.  But we have to be smart about it.  I volunteer for the job of deciding what's smart.

Medical Marijuana & Junk Science

Let me begin by denying having any expertise on medical marijuana.  I will also point out that the term "junk science" has been badly overused, and has been used to cast aspersions on evidence that really isn't junk science at all, including evidence for climate change and evolution.  So, for anyone who thinks I am applying this label to the study of which I am about to tell you because I'm a right-wing social conservative, that's not so.  It's just that I know real junk science when I see it.

I became aware of this study when a friend posted on Facebook a link to an article from a blog called "Smell the Truth," whose subtitle says it covers "medical marijuana news."  So, when I read the article from that blog, which put a very positive spin on the findings of the study it described, I thought I should read the original paper to see for myself.  And then I saw the title of the journal in which the study was published, Clinical Gastroenterology and Hepatology.  Hmmm.  Not a journal I routinely read, but the last time I read a paper published there, the study was so badly designed as to be laughable.  But let me keep an open mind. Surely the authors of the paper, and the editors of the journal, deserve that.  And no doubt the lead author's mother thought it was an excellent paper.

The study investigators wanted to know whether smoking marijuana might help patients with Crohn's disease.  This is an inflammatory disease of the bowel that tends to be a chronic, progressive disease that causes much misery.  It is challenging to control with medical therapy and not infrequently requires surgery to treat complications.

The study, conducted in Israel, took a group of patients with Crohn's Disease and randomized them to marijuana or placebo.  The patients were then followed over the next ten weeks, and their symptoms were quantified by the Crohn's Disease Activity Index (CDAI), a standardized research tool used to assess the effect of approaches to treatment.

The authors defined a CDAI score <150 as "complete remission." Without getting into the details of the scoring system, I should just point out that the term "complete remission" is misleading, as much of the score depends on symptoms that can wax and wane over a short period of time, while other elements of the score (4 of the 8 elements) relate to complications that occur over a longer time.
So it is possible to achieve substantial reductions in the CDAI through short-term symptomatic relief without any real change in underlying disease activity.  To call such an effect "complete remission," then, may give us the wrong impression of what is happening.
It would be more accurate to describe the effect as what it is, namely short-term symptomatic relief.

Of course the "Smell the Truth" blog trumpeted the phrase "complete remission" and said the treatment "performed like a champ."

But let us move on to the design of the study, so I can skewer that before I tell you about the results.

The number of patients was a mere 21.  This is very small - in fact, inexplicably so.  This is because the smaller the study, the less likely it is to find significant differences between the treatment and control groups (the "control group" consisting of patients who did not receive the treatment, typically receiving a placebo, or "sham" treatment, instead).  I will repeat my favorite example of this. Everyone understands that, when you flip a coin, it has an equal chance of coming up heads or tails.  If you flip it twice, however, it could easily come up heads twice or tails twice, and if you didn't understand the effect of sample size, you could easily be misled about the probabilities.  If you flip it 1,000 times, you will get pretty close to 500 each heads and tails - and learn the truth.

Anyone who engages in scientific research should understand the effect of sample size on the value of the results and can do something biostatisticians call a "power calculation" to figure out how big the study has to be to yield meaningful results.  Assuming these researchers were not clueless, and assuming they had access to someone who knew enough stats to do a power calculation, the only explanation for doing such a small study is that they intended it to be a very preliminary pilot study, a sort of "proof of concept" trial.  But that isn't how it was reported in the journal.

So the small sample size is major flaw #1.  Often a single major flaw is enough to render a study useless in telling us anything worth knowing.  But there's more.

When one does a study to test the effects of a treatment, the best design is what's called a randomized, controlled trial (or RCT), and an RCT is best done in a way that is "placebo-controlled" and "blinded."  Ideally it should be "double-blind," which means that neither the subjects (patients) nor investigators know which subjects got active treatment and which got placebo.  Often, from the subjects' perspective, placebo control and blinding are closely intertwined.  It is easy to see the challenge of placebo control and blinding in this study.

Subjects randomly assigned to the active treatment group smoked marijuana cigarettes containing a standardized amount of tetrahydrocannabinol (THC, the important active ingredient).  The control subjects smoked "sham" cigarettes made from cannabis flowers from which the THC had been extracted.

Now, remember, in order for the desired effects of blinding and placebo control to operate, the subjects in each group must not be able to tell whether they are receiving active drug or placebo.  Imagine you are taking a medicine to treat depression, an illness with mostly subjective symptoms.  If you are in a study, and you don't know whether you are taking active drug or placebo, you could easily be taking placebo yet experience improvement because you think maybe it's the active drug: the "placebo effect," which is very real and often surprisingly powerful.

So how could blinding and the placebo effect work in this trial?  Let us assume, giving the authors maximum benefit of the doubt, that they recruited only subjects who had never smoked marijuana and who would therefore be unfamiliar, at least from personal experience, with its effects.  (The paper didn't say that, and so it probably isn't true, but I'm trying to help them out here.)  Even then, subjects probably all had at least some idea what marijuana is supposed to do and could very easily tell when they smoked their cigarettes, real or sham, which they were. So there could not possibly have been any real placebo control or blinding effect. And that is major flaw #2.

The remaining major flaw, which is also related to sample size, is the importance of randomization.  The value of randomization is that it helps to minimize the chance that the subjects who've been enrolled are sufficiently different, between the two groups - in some way that the investigators may not even have realized could matter - as to affect the results.  For example, let's go back to testing the new medicine for depression.  Suppose we look at the two groups and find that the active treatment group did better than the placebo group.  But then suppose we go back and ask all the subjects whether, during the study, they happened to acquire a new boyfriend or girlfriend, and it just so happens that far more in the active treatment group than in the control group say yes.  We would then have no idea whether they felt better because of the new relationship or the treatment, or whether the treatment helped them get into a new relationship.  This is what researchers call a "confounder."  The effect of randomization is to minimize the role of confounders, and the larger the sample size, the more effective randomization is in accomplishing this.

So now that you know the three major flaws, let's look at the results.  Of the 11 subjects in the cannabis group, 5 achieved "complete remission," meaning short-term symptomatic improvement, while this was achieved for only 1 of 10 in the control group.  Looks like a big difference, right?  Well, because the sample size is so small, statistical calculations tell us there is a 43% likelihood this difference was due purely to random chance!  Thus, for the primary outcome measure, the main thing investigators were testing for, they found no difference with active treatment.  The most positive spin you can put on this, while maintaining scientific objectivity, is that there was a "trend" toward improvement that might turn out to be real in a larger study.  To their credit, part of their conclusion says a larger study should be done, and a "non-inhaled" form of the drug should be tested.  But that did not deter them from spinning the results as positive: cannabis "produced significant clinical benefits ... without side effects."

That last phrase didn't quite get me to laugh out loud, but I did find it quite amusing.  "Without side effects?"  That is nothing short of hilarious.  Any effect of a drug that is not the intended effect is, by definition, a side effect.  And so all of the effects of smoking marijuana that were not related to ameliorating the symptoms of Crohn's Disease were side effects.  Anyone who knows even a little about marijuana knows that users experience several completely unrelated effects.  These may not have been side effects that caused subjects distress or made them decide to drop out of the study.  But they were most definitely side effects.

So what does this study actually tell us?  We now know that researchers in Israel have studied medical marijuana for Crohn's Disease, and some patients experienced short-term symptomatic improvement.  This was only a trend, and the sample size was so small that the difference could have been due purely to random chance and must be tested in a much larger study before we will know anything with any confidence.  Finally, this study cannot tell us anything about longer-term effects of marijuana on Crohn's patients, either positive or negative. There is no known medical reason to suspect it has any effect on the pathophysiology of the disease, and so it would not be expected to have any effect on the frequency of exacerbations or development of complications.

This study will be touted by advocates for medical marijuana and by those who support decriminalization or complete legalization.  And now you know just what the study tells us - and what it doesn't.

 

Walk for the Homeless, Part 2

Geese and Goslings participating in the Walk

It was a cool, gray pearl of a day.  Nothing shy of perfection for this event.

I don't care for hot weather. Not even warm weather.  And I don't like to drive in snow and ice.  So if I picked a city to move to just for weather, it would be San Francisco.  No snow, no ice, mild winters.  And the summers are not hot.  The warmest month is September, when the average daily high is 71.  On average there are fewer than 30 days a year on which the high temperature exceeds 75.

Mark Twain famously said, "The coldest winter I ever spent was a summer in San Francisco."  I shall now pause to allow you to do a bit of Web research to discover that the general consensus is that Twain never actually said (or wrote) that, and no one seems to know who did.  Even more vexing, I could not find out who first called my favorite city the "cool, gray pearl."

The forecast was for showers.  And indeed there was an intermittent, light drizzle as I was driving into the city.  When I got out of my car at Heinz Field, though, it was chilly but not raining.  I had worn shorts and a T-shirt, and the temperature was barely 60.

Inside the stadium were far more people than I had expected.  I had registered online for this event, and I had done all of my fundraising online, too.  The total number of people who had done this was less than 60.  But when I got in line to sign in, it was clear this was a much bigger deal.  Apparently many people do things the old fashioned way, using paper forms and asking people at work and in their neighborhoods and social circles to give.  Then they show up and register on the day of the Walk.  The turnout was about a thousand: roughly 900 walkers and about 100 volunteers who were not walking but helping with everything else.

There was coffee (for which I was grateful), and fruit and cookies for breakfast. Before the Walk began we were addressed by the former Steelers whose names are on the Walk, Tunch Ilkin and Craig Wolfley, and we were introduced to various local dignitaries who came to lend their support, including members of City Council, and the Steelers organization, and the local news media.  Former Steelers running back Rocky Bleier looked healthy and fit.  And WTAE's Sally Wiggin was there.

[I don't watch local news much, which is a whole 'nother subject I may write about some day, so I decided to read up on Sally Wiggin, who has been a news anchor in Pittsburgh for over 30 years.  "Not just another pretty face" is an understatement.  Phi Beta Kappa.  Studied Japanese and has degrees in East Asian History and Chinese History.  A string of journalism awards.  Wow.]

Tunch and Wolf told us about how, when this annual event began more than a decade ago there were a dozen people walking.  It was really heartening to see that so many people had turned out this year.

And so we got underway.  It's still pretty chilly, I thought, as we left the stadium. But I knew that feeling wouldn't last.  Sure enough, by the time I had walked a kilometer or so of the 10K, I thought the temperature was ideal.

Many of my friends seem to spend most of their waking hours taking pictures and posting them on Facebook.  I've never been much of a photographer, although the fact that I am now never without a camera (aka smartphone) makes it easy. So I decided I should have at least one picture to accompany this essay, and there it was at the top of the page.

A brisk walking pace doesn't inhibit conversation, and there was plenty of that. Some people I talked to had been doing the walk for years.  Others had known about it but only this year had signed up to join the effort.  Still others, like me, had never heard of it until last month.  A few were people who'd volunteered at the shelter, and one was an employee of the Light of Life Ministries.  Some had interesting questions.  I think there were more questions than answers.

One lady wanted to know how many homeless there were in Pittsburgh.  She realized as soon as she finished the question that there was surely no definitive answer.  After all, the very fact of homelessness means you won't get a survey from the Census Bureau.  Doing a Web search, I found figures in the 1300-1500 range for recent years in Pittsburgh.  But part of the challenge is getting started: you have to define the problem.

Everyone would agree that if you're living on the street, sleeping under a bridge, or staying in a shelter, you're homeless.  But in some studies of social problems, the term "homeless" is defined much more broadly.  You are living in an apartment that you can barely afford, the landlord decides to convert to condos, you don't qualify for a mortgage, and you can't find another place to live before you're evicted.  A cousin has a spare bedroom and takes you in.  You're homeless.  No, not like the person living in a big cardboard box positioned over a subway grate on the street in a big city, but categorized that way in some studies of homelessness as a social problem.  That isn't helpful, because it makes people who have charitable impulses or who are inclined toward spending public dollars to ameliorate the plight of the homeless think maybe the problem is being overstated.

I've spent time in a lot of medium-sized and larger cities in the United States. Take my word for it, if you are willing: the problem is big enough without anyone overstating it.

The folks at Light of Life do not, I think, devote a great deal of effort to quantifying the problem.  They're too busy trying to solve it, one homeless person or family at a time.  Food, shelter, clothing.  Counseling for personal problems.  Treatment for mental illness and addiction.  Help with education and training. They teach people what they need to know to obtain a GED (the credential in General Educational Development that is widely accepted as equivalent to a high school diploma). They've helped homeless people enroll in Community College of Allegheny County and obtain degrees from CCAC.  One worker told me proudly about a fellow who had transferred his CCAC credits and was in a degree program at the University of Pittsburgh.

At the end of the walk there was a very nice lunch.  And some more conversation.  There were T-shirts for everyone who had raised at least a certain amount of money for the walk or paid a nominal sum.  Most of us had picked them up before the Walk, and many wore them.  I did, although I really didn't need the extra layer.

I have a confession to make.  (This is for those who don't know me well.  Those who do will nod in immediate recognition.)  I have a very mischievous sense of humor.  So I thought about saying, in a stage whisper, if I ever got the chance, "I don't give a damn about the homeless.  I'm just here for the T-shirt and the exercise."  But everyone was so sincere, and enthusiastic, and upbeat about what they were doing that morning.  I couldn't bring myself to say it, because I wouldn't want anyone to think I actually meant that, even for an instant.  I was happy to be a part of it.  Happy to be doing something to help people who, I sometimes think in moments of gloom, are beyond help.  The folks at Light of Life know that's not true.  They don't believe anyone is beyond help.